Don't Go Breaking My Heart

Author: Justine Ko, MD

Peer-reviewer: Terese Whipple, MD

Final editor: Alex Tomesch, MD

A 45-year old male presents to the emergency department with chest pain after a high-speed motor vehicle accident where his chest hit the steering wheel. He is complaining of central chest pain and there is ecchymosis noted over his sternum.

Image 1. Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID: 26332

1. What is your diagnosis?

2. What is your management in the ED?

3. What is your disposition? 

-- see below for answers --

1. What is your diagnosis?

The patient is diagnosed with a sternal fracture. These fractures are associated with deceleration injuries and trauma to the anterior chest [1]. Patients present with chest pain that worsens with respirations and shortness of breath [2].

• Pearl: An AP and lateral chest x-ray is the initial imaging modality of choice. However, a CT scan can be performed to better characterize the fracture and its sequelae [2].

Image 2: Case courtesy of Dr Jayanth Keshavamurthy, Radiopaedia.org, rID: 38447

2. What is your management in the ED?

Management in the ED follows ATLS guidelines and resuscitation. These injuries are frequently associated with other injuries, such as hemothorax, pneumothorax, and flail chest. The mainstay of treatment in isolated, nondisplaced fractures is analgesia. Displaced fractures may require operative management by the trauma team. Similar to management of rib fractures, deep breathing and incentive spirometry is recommended to avoid pulmonary complications [1,2].

• Pearl: Look for blunt cardiac injury in these patients. Cardiac biomarkers, an ECG, and telemonitoring should be performed in patients presenting with this injury [1].

3. What is your disposition?

Isolated, nondisplaced sternal fractures in patients without evidence of cardiac injury can be safely discharged with close followup. Those with signs of blunt cardiac injury should be admitted for further monitoring [1].

References:

1. Khoriati A, Rajakulasingam R, Shah R. Sternal fractures and their management. J Emerg Trauma Shock. 2013;6(2):113-116. doi:10.4103/0974-2700.110763

2. Bentley TP, Ponnarasu S, Journey JD. Sternal Fracture. In: StatPearls. StatPearls Publishing; 2021. Accessed July 8, 2021. http://www.ncbi.nlm.nih.gov/books/NBK507790/

Sign up here to receive our weekly cases

Want to write? Email us at orthoempearls@gmail.com

Instagram/Twitter: @orthoempearls

www.orthoempearls.blogspot.com